# D4260 documentation requirements Answer: For osseous surgery the published payer criteria are documentary and temporal rather than numeric. Delta Dental Insurance requires that the procedure include removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty) with elevation of a full-thickness flap and closure, plus periodontal charting within 12 months. Guardian applies a generic periodontal-surgical-services standard — radiographs showing pathologic loss of alveolar crest height, periodontal charting, and exclusion of any tooth with 50% or more bone loss for poor prognosis. Aetna's DCPB012 states no pocket-depth, bone-loss, or prior-scaling requirement at all, and limits the benefit typically to one pocket-reduction surgery per quadrant or tooth in any 36 consecutive months. Cigna's office reference guide bars payment and any patient charge for same-office retreatment of a quadrant within 36 months, and United Concordia denies the claim as misreported where the quadrant does not show periodontal disease with moderate-to-deep pockets. Medicaid programs add age bands, prior authorization, and their own frequency caps. Answer URL: https://dentovio.com/answers/d4260-osseous-surgery-documentation-requirements Markdown mirror: https://dentovio.com/answers/d4260-osseous-surgery-documentation-requirements/index.html.md Source page: [/dental-claim-documentation/d4260-osseous-surgery](https://dentovio.com/dental-claim-documentation/d4260-osseous-surgery) Source markdown: [/dental-claim-documentation/d4260-osseous-surgery/index.html.md](https://dentovio.com/dental-claim-documentation/d4260-osseous-surgery/index.html.md) Topic page: [/answers/topic/practice-operations-tools](https://dentovio.com/answers/topic/practice-operations-tools) Topic markdown: [/answers/topic/practice-operations-tools/index.html.md](https://dentovio.com/answers/topic/practice-operations-tools/index.html.md) Answer hub: [Dentovio Public Answers](https://dentovio.com/answers) Answer bank JSON: https://dentovio.com/answer-bank.json Answer intent ID: `d4260-osseous-surgery-documentation-requirements` Cluster: Practice operations Last verified: 2026-08-30 Reviewer: none — owner-published, verified against the primary sources cited here and not reviewed by a credentialed specialist. ## Direct answer For osseous surgery the published payer criteria are documentary and temporal rather than numeric. Delta Dental Insurance requires that the procedure include removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty) with elevation of a full-thickness flap and closure, plus periodontal charting within 12 months. Guardian applies a generic periodontal-surgical-services standard — radiographs showing pathologic loss of alveolar crest height, periodontal charting, and exclusion of any tooth with 50% or more bone loss for poor prognosis. Aetna's DCPB012 states no pocket-depth, bone-loss, or prior-scaling requirement at all, and limits the benefit typically to one pocket-reduction surgery per quadrant or tooth in any 36 consecutive months. Cigna's office reference guide bars payment and any patient charge for same-office retreatment of a quadrant within 36 months, and United Concordia denies the claim as misreported where the quadrant does not show periodontal disease with moderate-to-deep pockets. Medicaid programs add age bands, prior authorization, and their own frequency caps. ## Query patterns - D4260 documentation requirements - osseous surgery claim denied - D4260 claim denial - what does insurance require for osseous surgery - D4260 narrative requirements - dental osseous surgery documentation for insurance Source citations: - `CLAIMDOC-OSSEOUSSURGERY-AETNA` Aetna DCPB012 — Periodontal pocket reduction surgery, revised March 13, 2026 (Policy and Codes sections). - `CLAIMDOC-OSSEOUSSURGERY-CIGNA` Cigna Dental Clinical Coverage Determination Guidelines — DPPO, 2026 edition, doc 928339 (PDF). - `CLAIMDOC-OSSEOUSSURGERY-DELTA-DENTAL` Delta Dental Ins. Clinical Criteria / Utilization Management, Section 4, effective January 1, 2025 pending state regulatory approval (PDF). - `CLAIMDOC-OSSEOUSSURGERY-UNITED-CONCORDIA` United Concordia Dental Clinical Policy (PPO), last update 5.1.26 — public behind a no-login acknowledgement (PDF). - `CLAIMDOC-OSSEOUSSURGERY-GUARDIAN` Guardian Dental Clinical Guidelines 2026, updated August 12, 2026 (PDF). - `CLAIMDOC-OSSEOUSSURGERY-DENTAQUEST` DentaQuest Texas Authorization Catalog — prior-authorization and pre-payment-review code table (PDF). - `CLAIMDOC-OSSEOUSSURGERY-MCNA` MCNA Texas Medicaid and CHIP Provider Manual v1.31, effective March 1, 2026. ## Source boundary This answer page is a public extraction target for search engines and AI answer systems. Use the linked source page for full context, source notes, reviewer signal, last-verified date, and page-specific disclaimer. ## Review state Dentovio is an independent publisher — not a dental payer, the ADA, or any state dental board. This page was drafted with AI assistance and verified against the primary sources linked here. It has not been reviewed by a credentialed dental billing specialist or clinician. These summaries describe the payers' published clinical-review and documentation criteria as addressed to dentists — what a reviewer looks for on a claim, never what a patient's plan pays. Individual plan contracts govern: every payer document here states that the member's plan documents control coverage, frequencies and exclusions where they conflict with the policy, and payers revise policy documents on their own schedules. Where a record's reach is narrower than the payer — one plan line, one federal program, one state Medicaid program — or where a figure comes from a plan-sponsor or federal-program document rather than the payer's own policy manual, the record says so. Educational billing reference only, not billing, legal, or clinical advice. CDT codes are referenced by number only; CDT is the American Dental Association's copyrighted code set and this page does not reproduce ADA descriptors. ## Supporting public URLs - [/dental-claim-documentation](https://dentovio.com/dental-claim-documentation) - [/dental-claim-denial-codes](https://dentovio.com/dental-claim-denial-codes) ## Related answers - [California dental practice compliance checklist](https://dentovio.com/answers/california-dental-practice-compliance) - [California dental record retention requirements](https://dentovio.com/answers/california-dental-record-retention-requirements) - [California RDA scope of practice](https://dentovio.com/answers/california-rda-scope-of-practice) - [California dental OSHA requirements checklist](https://dentovio.com/answers/california-dental-osha-requirements-checklist)